Temporomandibular Joint Ankylosis-A Case Report

Temporomandibular Joint (TMJ) ankylosis is a condition in which condylar movement is limited by a mechanical problem in the joint (“true ankylosis”) or by a mechanical cause not related to joint components (“false ankylosis”). True ankylosis may be bony or fibrous. In bony ankylosis, the condyle or ramus is attached to the temporal or zygomatic bone by an osseous bridge. In fibrous ankylosis a soft tissue (fibrous) union of joint components occurs; the bone components appear normal. False ankylosis may result from conditions that inhibit condylar movement, such as muscle spasm, myositis ossificans, or coronoid process hyperplasia. Most unilateral cases are caused by mandibular trauma or infection. The most common cause of bilateral TMJ ankylosis is rheumatoid arthritis, although in rare cases bilateral fracture may be the cause. Here we report a case of TMJ ankylosis in a 30 year-old male patient showing most of the characteristic features of this condition.


INTRODUCTION
Temporomandibular joint (TMJ) Ankylosis involves fusion of the mandibular condyle to the base of the skull.When it occurs in a child, it can have devastating effects on the future growth and development of the jaws and teeth.Furthermore, in many cases it has a profoundly negative influence on the psychosocial development of the patient, because of the obvious facial deformity, which worsens with growth.Trauma and infection are the leading causes of ankylosis 1 .However, in a young patient a joint injury may not be noticed immediately.The first sign of a significant problem may be increasing limitation of jaw opening, usually noticed by the dentist.Pain is uncommon.

Temporomandibular Joint Ankylosis -A Case Report
DIVYA M MEHTA 1 , V. ANAND 1 , J. JENITA JACOBINA 2 , G.S. ASOKAN 1 , N. BALAJI 1 and S. ASWINI 1 Early diagnosis and treatment are crucial if the worst sequelae of this condition are to be avoided.Optimal results can be achieved only after a complete assessment and development of a longterm treatment plan.

Case Report
A 30-year-old male patient reported to our department with a chief complaint of difficulty in opening his mouth with a history of difficulty in eating food and habit of mouth breathing.There was no history of a forceps delivery.There was a trauma 22 years back.He gave a history of surgical treatment of the problem in 1992, 1996 and 2000 in different hospitals.He admitted that he did not follow up the exercises said to him after the surgeries.There was no relevant history of ear infection, weight loss, drug history and family history.
On general physical examination he was of medium built, his height was 5.5 feet and his weight 57 kg.His gait was normal.There was no sign of icterus, pallor and anaemia.
Intraoral examination revealed mouth opening was restricted to 2mm.Occlusion is seen on the right side.(fig 3)There was discolouration of 42 with a periapical abscess(fig 4).He gave a history of extractions of 32, 33, 34, 35, 36, 37.The orthopantomogram (fig.5), revealed prominent antigonial notch on both sides and narrow joint spaces.Patient was not willing to undertake CT scan.
A proper treatment plan was explained to the patient but he was not willing to undergo any further surgical management.However, he was explained that unless surgical approach along with physiotherapy is done the condition cannot be resolved.Few mouth opening exercises where taught to him and he was referred to department of oral and maxillofacial surgery for further management.
administered which includes surgical intervention, elaborate resection early mobilization and aggressive physiotherapy for at least six months to one year postoperatively 6 .
Early aggressive postoperative physiotherapy has been recognized as an essential aid for the prevention or treatment of TMJ hypo mobility or ankylosis.
The biological and physiological basis for increasing the range of motion using dynamic exercise in restoring normal functions after surgery and prolonged immobilization has been well documented in trauma, orthopaedic and physical therapy literature.The potential benefits of TMJ opening and closing exercises are improved muscle vascularity, increased muscle mass and protein metabolism, decreased muscle fatigue and increased strength, reversal of the atrophic and degenerative changes within the joints and restoration of the normal internal fibrous structure anatomy 8 .
Interpositional Gap Arthroplasty is a highly effective and safe surgical management option for TMJ ankylosis with acceptable immediate and long term outcome, particularly when temporalis fascia and muscle are used for adults and costochondral grafts with fascia interposition used for children 9 .A seven step protocol has been developed for the treatment of TMJ ankylosis: -1) Aggressive resection of the Ankylosis segment, 2) Ipsilateral coronoidectomy, 3) Contralateral coronoidectomy when necessary, 4) Lining of the joint with temporalis fascia or cartilage, 5) Reconstruction of the ramus with a costochondral grafts 6) Rigid fixation of the graft and 7) Early mobilization and aggressive physiotherapy 10 .

CONCLUSION
Ankylosis of the TMJ is a serious health compromising condition of children and growing teenagers, which prevents normal feeding habits, The causes are inflammatory destruction of synovial lining of the joint.Inflammation may result from, primary infection of joint, extension from neighbouring infection such as otitis media, mastoiditis, osteomyelitis of mandible, blood-borne infection from several sources, trauma to the joint, rheumatoid diseases like rheumatoid arthritis, ankylosing spondylitis and Reiter's syndrome, and Hemarthrosis (such as those occurring in haemophiliacs).
Children are more prone to ankylosis because of greater osteogenic potential and an incompletely formed disc.Ankylosis frequently results from prolonged immobilization following condylar fracture 5 .
Moreover in case of TMJ ankylosis, an appropriate worldwide accepted protocol is to be impairs speech and causes facial deformity and affects social life; but with early proper diagnosis, and when adequate surgical intervention is carried out on time, with good patient cooperation and with an intensive follow-up, the prognosis is good.

Fig. 3 :
Fig. 3: Shows occlusion in the right side

Fig. 5 :
Fig. 5: Shows prominent antigonial notch on both left and right sides DISCUSSION